A large trial conducted at community health centers in the United States shows that mailed FIT-DNA kits outperform FIT in facilitating colorectal cancer screening. Nevertheless, fewer than 4 in 10 patients with abnormal results complete a follow-up colonoscopy.
Study: Mailed Outreach for Colorectal Cancer Screening in Community Health Centers. Image credit: Orawan Pattarawimonchai/Shutterstock.com
Fecal immunochemical testing-DNA may be a more effective mail outreach approach than fecal immunochemical testing to increase colorectal cancer screening rates among adults receiving primary care at community health centers, reports a new study published in 2016. JAMA Internal Medicine.
Colon cancer screening gaps persist in underserved community health centers
Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States. People living in disadvantaged environments are more likely to develop this cancer. Timely screening can reduce the incidence and mortality of colorectal cancer, but it remains poorly implemented, especially in community health centers that provide primary care to at-risk populations.
Fecal immunochemical testing (FIT) is a cost-effective screening approach for CRC that is widely used in community health centers. New evidence of an upward trend Utilize a mail-based FIT outreach approach to increase FIT adoption.
FIT-DNA is a new screening test that is typically performed every three years and is mailed directly to patients. Delivered to manufacturers as part of a structured outreach and support program. For both FIT and FIT-DNA, follow-up colonoscopy is required if the results are abnormal. Recent evidence indicates that patients who receive mailed FIT outreach are significantly more likely to complete screening than those who do not.
FIT-DNA is more sensitive than FIT based on previous evidence and is typically performed at the direction of a clinician, although with manufacturer-supported outreach, direct involvement of community health center staff may be less required. These factors make FIT-DNA a potentially advantageous approach to improve CRC screening and outcomes.
The current study was designed to compare the effectiveness of mail-based FIT and FIT-DNA outreach approaches to increase colorectal cancer screening uptake in community health centers.
Comparing email outreach strategies and navigation support
Eight community health centers in the Boston metropolitan area and Los Angeles participated in the study. Adults aged 45 to 75 years who were scheduled for CRC testing and receiving primary treatment at included community health centers were eligible for enrollment.
All participants received either a mailed FIT with automated text message outreach from study personnel or a mailed FIT-DNA with the manufacturer’s outreach protocol. Participants with abnormal FIT or FIT-DNA results were provided with standardized navigational support to facilitate colonoscopy completion.
The primary objective of this study was to assess participation in CRC screening within 90 days after administration of either FIT or FIT-DNA. Screening participation within 180 days and time to screening participation were also assessed.
The spread of FIT-DNA has significantly increased screening participation rates.
A total of 5,127 people were enrolled in the study. Approximately 48% were randomized to the FIT group and 52% to the FIT-DNA group.
Analyzes showed significantly higher screening participation rates in the FIT-DNA group than in the FIT group at 90 and 180 days. Time to screening participation was shorter in the FIT-DNA group. Of the two sites, the overall number of screening participants was higher in Boston than in Los Angeles at both time points. However, the relative superiority of FIT-DNA over FIT was more pronounced in Los Angeles.
Of the 1,435 participants screened, 100 had abnormal test results. Of these, 36 completed a colonoscopy within 180 days.
Widespread use of FIT-DNA could improve screening of underserved populations
Study results indicate that implementing mail-based FIT-DNA outreach at community health centers can significantly increase CRC screening participation and reduce time to screening participation. However, regardless of the type of mail outreach approach, participation in colonoscopies after abnormal screening test results remains suboptimal.
Several factors may explain the observed increase in screening participation using FIT-DNA. Manufacturer patient assistance programs provide better support than mail-based FIT outreach with automatic reminders. This is the maximum level of support typically achievable at community health centers. Additionally, the longer screening interval (every 3 years) and higher test sensitivity may have increased participants’ willingness to take advantage of the FIT-DNA option.
Compared with the manufacturer’s average, the FIT-DNA was less complete in this study, likely due to persistent social and economic barriers to screening of at-risk populations. Clinician influence may also come into play here, as FIT-DNA is typically ordered by the clinician after discussion with the patient.
As observed in the study, overall screening participation rates were higher in Boston. At the same time, the difference between FIT-DNA and FIT was larger in Los Angeles, suggesting regional differences depending on outreach strategy. This difference may be due to differences in patient characteristics in these two areas. In Los Angeles, the majority of study participants were Hispanic, Spanish-speaking, and uninsured. These factors may partly explain the low participation in colorectal cancer screening in this region.
Taken together, these findings highlight the importance of implementing mail-based FIT-DNA assistance to increase colorectal cancer screening uptake among individuals who rely on community health centers for primary care. However, the lower colonoscopy completion rates observed in this study highlight the need for effective strategies to motivate those with abnormal screening test results to undergo follow-up colonoscopies to improve the prognosis of CRC.
Community health centers in Boston and Los Angeles use different FIT kit brands, which may account for the higher rate of abnormal results in the Los Angeles community health center. In light of this finding, the researchers recommend considering FIT performance when selecting a FIT kit for routine use, as differences in test performance can influence the number of abnormal results and the need for subsequent colonoscopy, rather than explicitly indicating a high false-positive rate.
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